Department of Pathology
and Laboratory Medicine

Akron Children's Hospital
One Perkins Square
Akron, OH 44308
Laboratory
Ph: (330) 543-8573
Fax: (330) 543-3659

LABORATORY TEST REQUISITION


PATIENT INFO
Patient Name:
Medical Record #:
BD:        /        /              Sex:    F    M

PHYSICIAN INFO
Physician Name :
Address:
Ph: (        )        -              Fax: (        )        -              
Additional Report to:
Ph: (        )        -              Fax: (        )        -              

TESTS REQUESTED
Test Name: ICD9 Code: (required)
1. Group A Strep Ag   
2.   
3.   
4.   
5.   
6.   

SPECIMEN INFO
Collection Date & Time:
Collected By:
Test Information for Group A Strep Ag
CPT Code: 87430

Specimen Type: Throat swab

Tube Type/Collection Container: Rapid strep dual swab, obtain from Central Supply

Collection Volume: 1 dual swab

Cause for rejection: Incorrect swab used to collect specimen, any specimen type other than throat

Storage: Ambient

Availability: Daily

Methodology: Immunochromatographic Assay

Special Instructions: To obtain the best results, two swabs should be used together to swab the back of the throat and tonsillar area. The extra swab may be used for Strep culture if ordered. Deliver to lab ASAP. The Strep culture must be ordered in addition to the Group A Strep Ag test. If the Group A Strep Ag is positive, a Strep culture is not done. Note:The Rapid Strep test has not been validated for rectal swab specimens.

TAT: 30 minutes


Lab/Phone: 330-543-8412

Additional Info: -

Transport specimens to processing area of the laboratory in an appropriate container. Additional information is available from Cindy Maurer at (330)543-8689.

SHIP TO:
Department of Pathology and Laboratory Medicine
CCL
Akron Children's Hospital
One Perkins Square
Akron, OH 44308


Physician Signature: Date: